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Ulcus Ventriculi / Ulcers of the Stomach

An ulcer is a breach in continuity of the inner lining (mucous membrane) of a hollow organ.

Thus stomach ulcer means a localized defect in the inner lining of the stomach wall that results from excessive acid production and insufficiency of the mucous membrane.

Causes

Common causes are excessive stress, chronic misuse of medication e.g. of non-steroidal anti inflammatory drugs (NSAIDs), helicobacter pylori (H.Pylori) bacterial infection and smoking.

It is more common in males than in females. 

 

Symptoms

The most common symptom is diffuse pain or discomfort in the middle of the upper abdomen (epigastrium) either immediately after having eaten something or up to one to two hours later. Heartburn and loss of weight are other common symptoms. Further non-specific symptoms are a feeling of pressure and fullness, nausea, and loss of appetite. 

 

Diagnosis

The diagnosis is made through a study of the patient's history (anamnesis) and physical examination. A gastroscopy is used for confirmation, whereby obtaining tissue samples (a biopsy) is a must to check for H. Pylori infection as well to rule out presence of cancer (malignancy). 

 

Treatment

If it is confirmed with the help of the biopsy that it is a benign ulcer, the initial treatment would be conservative. Coffee, alcohol, and nicotine should be avoided and any medication having an ill-effect on the mucous membrane is discontinued (mainly certain pain killers). In addition medication which inhibits acid production, called proton pump inhibitor, is administered. If infection of the helicobactor bacterium has been confirmed, a triple drug therapy must be administered.

 

Indications for Surgery

Surgery would only be indicated if there is an evidence of a rupture (perforation), if the bleeding from the ulcer cannot be managed endoscopically (with a gastroscope), and if there is positive evidence of a tumour or maligancy.

Another possible indication for surgery would be a recurring ulcer which doesn't heal with the conservative line of treatment or the presence of a giant ulcer.

Today only a few stomach ulcers need surgery thanks to the availability of highly effective drugs.

 

Surgical Therapy

The preferred therapy for ulcer perforation is an early removal of the ulcer and closure by surgical stiching of the stomach wall. Access to the ulcer is achieved through a vertical incision in the middle of the abdomen. If the ulcer is located on the front wall of the stomach, the procedure can be done using laparoscopy. If, however the ulcer is too big, the perforation is older than a few hours, or the location of the ulcer is unfavorable, open surgery must be performed. The partial stomach resection (removal) according to Billroth I, is done by detaching the duodenum, removing the affected part of the stomach, and stitching the remaining stomach directly onto the duodenum. The partial stomach resection according to Billroth II, is done much the same, however, the remaining stomach is stitched to a section of the middle of the small intestine (Jejunum) and the detached duodenum is closed 

 

Complications

Serious complications of an ulcer are acute or chronic bleeding from the base of the ulcer, rupture or perforation when the ulcer "digs" through all the wall layers, or if it grows into adjacent organs e.g. the pancreas. Further there is a high risk of ulcers becoming cancerous.

 

Risks of surgery are insufficiency of the stitches resulting in the emptying of stomach contents into the abdominal cavity and (rarely) emptying disorders of the stomach

 

Follow-up

Ulcers either treated with conservative methods or with surgery, must be regularly checked by means of a gastroscopy. If an ulcer hasn't healed 3 months after drug therapy has been started, a new biopsy must be done to determine if a malignant disease is present, making surgery necessary.